DEC. 15, 2003. On a typically damp, gray May morning, the neighborhood of Krasnoselski in St. Petersburg looks gloomy and desolate. Just off the highway nearby stand several massive, unadorned low-income apartment complexes, modern-day sentinels towering above a barren, garbage-strewn urban landscape.

The air coming off the Baltic Sea is frigid and few residents loiter outdoors. But several people huddle outside a RV parked on a side road, smoking and chatting, before stepping back inside.

The RV is a mobile clinic that belongs to Humanitarian Action, a new nonprofit organization affiliated with the French humanitarian agency Médecins du Monde (Doctors of the World), an offshoot of the better-known Médecins sans Frontières (MSF; Doctors Without Borders).

It parks here every afternoon, at one of two mobile needle exchange sites that are viewed as the frontlines of Russia's battle against AIDS. A short time after its arrival, people quietly begin slipping out of the surrounding buildings and make their way over.

Inside, space is so cramped that counselors and nurses must shuffle their legs to allow others to come and go. Most stop at a small window where, after giving their first names only, they hand over used syringes in exchange for fresh ones. Over 230,000 syringes are given out a year by the program, and 98 percent are traded for used ones.

The program is one of 43 harm reduction programs in Russia and the other eleven former Soviet-bloc countries of the Commonwealth of Independent States (CIS). It is backed mostly by money from the US-based Soros Foundation and its Open Society Institute. The AIDS Foundation East-West (AFEW), a large organization that grew out of MSF-Holland's projects in the CIS region, sponsors their work.

A Bridge of Life
Inside the trailer, new clients step further back for an intake checkup by a nurse or doctor. Then they receive counseling and testing for HIV, tuberculosis (TB) and hepatitis. Many clients have all three.

They leave with referrals for follow-up tests and care at the city's AIDS program or the specialty AIDS ward at Botkin hospital. Some are referred to TB hospitals for X-rays and treatment or to STD clinics for gynecological and obstetrical services.

More and younger clients are getting pregnant, and few have access to prenatal care. Short of being a full-service medical provider, the program provides a bridge between groups at high-risk for HIV and Russia's sprawling public health system.

"We are a syringe-exchange point, but we noticed the need for care and treatment is very great in this population," explained Alexander Tsekhanovitch, who heads the mobile program.

"We feel that our program is not a polyclinic or an ambulance-on-wheels. It is a step between real life or the street and the health services of the city. We put them in touch  patients and doctors. Before we started here, there was no one connection between official services and these vulnerable groups. At the same time," he conceded, "what we are doing is very limited."

Many clients live on the street and need an array of services: food, jobs, housing. At the top of the list is drug addiction treatment, which is seriously lacking in Russia. Methadone use is outlawed and there are few rehab programs.

Most clients shoot heroin; many are hardcore addicts. Like sex workers, they tend to avoid anything official, including city healthcare services, fearing arrest or discrimination  for good reason, Tsekhanovitch reported.

"The general attitude toward drug users is very negative," he said. "The basic policy has been to lock them up. It is the same with prostitutes. Now you are adding HIV into the mix. I hate to say this, but many people would be just as happy to see them all die."

Doomsday Coming True
Harm reduction projects were just getting off the ground in 1999, a turning point in the epidemic, say health officials. Since that year, statistics show it has exploded at a rate that these officials call an E-curve, with annual new infections more than doubling the entire caseload of the previous period.

Up until now, the bulk of those affected have been drug addicts and sex workers who typically turn to prostitution to support their own drug habit. In this huge country of 143 million people, two million people now use drugs. Many have landed in prison, where HIV testing is mandatory.

Today, 37,000 of Russia's nearly 900,000 prisoners have HIV. Many are released with new infections of drug-resistant TB and hepatitis, crises that shadow the AIDS problem. Surveys have found that sex and drug use are common in prison while medical treatment is limited outside pilot projects run in four regions by AFEW and its allies.

Over the past year, Russian government warnings have started to match doomsday forecasts by AIDS groups that describe the epidemic in catastrophic terms, a giant waking bear that no one can fully grasp, never mind contain.

Russia officially claims 230,000 HIV cases, and 800 AIDS cases, including 191 children. Six hundred people have died over the years. This spring, Dr. Vadim Pokrovsky, the country's top AIDS scientist and head of the federal Center for AIDS Prevention and Treatment in Moscow, put Russia's HIV caseload at 1.5 million, with 4.5 hidden cases for every documented one.

These numbers are based on some almost 25 million HIV tests carried out in the general population each year for the past decade. Before 1996, only 600 cases were detected.

Others worry the low-ball AIDS estimate is missing a more serious problem. "The surveillance system is not useful if you don't have controlled sites or control groups among the highest-risk groups," said Pedro Chequer at the United Nations AIDS Programme (UNAIDS) Moscow office. Chequer is a Brazilian who helped develop the much-lauded AIDS treatment program in his country.

"They say they have 240,000 people but that AIDS cases are less than 1,000. That's not possible," he added, "Look at Brazil: it has 700,000 persons with HIV and 230,000 AIDS cases. So, something is not right here." But Dr. Pokrovsky maintains that the low AIDS caseload reflects HIV's late appearance in the region.

After the Fall
Russia's AIDS crisis has its roots in the fall of Communism in 1991. Russia not only embraced capitalism and "shock therapy" economic reforms, but what some call the freedoms and sins of the West, including hard drugs, and prostitution.

The privatization of national industries, including the bloated, corrupt health sector, also caused the rapid collapse of public services and outbreaks of disease. By 1996, alcoholism, TB, syphilis, gonorrhea, hepatitis B and C were endemic. A third of the country was jobless, while the number of drug addicts had jumped a hundredfold, overcrowding prisons.

Compared with elsewhere, the epidemic in the former Soviet bloc has a very young face. Eighty percent of HIV infections are in people under 30, and 20 percent are teenagers. In the Central Asian Republics, half of all cases are in youth under 20.

The epidemic was first concentrated in Moscow and St. Petersburg, but has spread to poorer, remote regions like Siberia, prompting one US political analyst to predict that the epidemic in Eurasia, if unchecked, could one day surpass that of sub-Saharan Africa.

Today, there are 500 to 800 newly registered HIV cases a week and a growing percentage are linked to heterosexual transmission, not drug use or homosexual contact. Federal statistics capture the trend: in 2001, the ratio of male-to-female cases was 10:1; now it is 4:1. At the mobile trailer site, the ratio has reached 1:1 among new cases. The average age of infected girls also has dropped to become 2.5 years younger than boys.

Girls Hit Hard
Behind these figures is a generation of Russian teenage girls who become heroin addicts, enter sex work, and then contract HIV and hepatitis. Throughout the region, a growing number of infants born to HIV-positive, drug-addicted women have been abandoned. These orphans live in hospitals, because no orphanages in Russia will accept them.

HIV is also rising among street children. At age 9 or 10, they start sniffing glue and are soon exposed to HIV through rape, and in the case of older children, prostitution; by 14 they are in informal gangs, shooting drugs, having sex with each other, picking up and passing on HIV. "We are talking about a situation that is unimaginable, even to us," admitted Alexander Tsekhanovitch, head of the mobile program. "We are still a little afraid to evaluate the status of things."